Fitting Child Flashcards
How common is it to have a seizure?
- 8% of children have one seizure by 15 years of age
- Most seizure stop by 2-3 minutes, from onset
- Longer the seizure last, the less likely it is to stop
- A child that presents to you fitting is likely in status epilepticus
Definition of status epilepticus?
- Prolonged seizure activity lasting greater than 30 minutes
- Recurrent seizures without the regain of consciousness lasting greater than 30 minutes
When do you start management for a seizure?
- 5 minutes as by then, it is likely to continual longer than this
When might a seizure cause long term sequelae?
30 minutes or longer
What is the mortality rate of status epilepticus?
- In past, mortality rates in children have ranged from 6-18%
- First year of life: 17.8%
- 0-6 months: 24%
- 6-12 months: 9%
What are the longterm complications of status epilepticus?
- Neurological sequelae of Convulsive SE
- Epilepsy,
- motor deficits,
- learning difficulties, and
- behaviour problems are age dependent
- occurring in 6% of >3 years
- but in 29 percent of those
What are the causes of status epilepticus?
- Prolonged Febrile Seizure – is the most common cause of Status Epilepticus ( 32 % )
- Febrile: sole provocation is fever
- Acute symptomatic (insults to the brain)
- CNS Insult: meningitis, encephalitis,
- Metabolic disturbance – hypoglycaemia
- Incracranial lesion – tumour/ head trauma,
- Remote Symptomatic :
- Past insult with resultant seizure disorder
- Remote Symptomatic with an acute precipitant –
- underlying seizure d/o but something ppt –
- just because underlying seizure disorder doesn’t always explain the status – e.g electrolyte disturbances
- Precipitants of SE: missed medications, sleep deprivation, fever & infections, medications that lower the seizure threshold
- Still Need to look for acute causes
How do you approach assessment of a seizure?
- BLS- DRSABCD
- Dangers- PPE – risk of COVID-19
- Sending for help
- Time the seizure
- ABCDE
- Maintain Airway- Provide oxygenation
- Monitor Breathing & Vital Signs
- Circulation- obtain IVaccess, BP
- Disability- responsiveness
- Exposure- rash / bruising as a sign of injury /measure temperature
- Fluids
- Glucose - DEFG : Dextrose: check glucose levels
- Electrolytes: check electrolytes (Na, Ca, Mg, PO4), and anticonvulsant levels
- History
- Description, warning, what was the child doing before the spell,
- Focal or tonic clonic
- Length of seizure
- Multiple clusters of seizure activity
- Examination
- Investigations
- Always do a blood glucose level (BGL), Calcium, Magnesium, other electrolytes Na,
- Venous blood gas
- Consider other investigations according to the possible underlying aetiology e.g. infectious screen anti-epileptic drug levels, toxic screen
What advice do you do for generalised ronic clonic seizures out of the hospital setting?
- DO
- Stay with person and protect from injury (especially the head)
- Time seizure
- Roll person on their side
- Monitor breathing
- Reassure person until recovered
- DON’T
- Put anything in person’s mouth
- Restrain the person
- Move person unless in danger
What do you do if a seizure last >5 minutes?
- Benzodiazepine Therapy
- Midazolam
- Dosage 0.15 mg/kg IV
- OR 0.3 mg/kg Buccal
- ( max 10 mg )
- 100 kg 15 years – 10 mg is still max
Describe the advanced paediatrics life support for seizures?
What do you do if a seizure goes on for 10 minutes?
- Intubate
- Another dose of Midazolam
- 2nd line- Phenytoin preferred
- Needs an urgent Venous blood gas to decide next step
- 2nd Line- Levetiracetam
Another dose of Midazolam
When do you give a second line anticonvulsant in a prolonged seizure?
- 1 minute
- 2-3 minutes
- 5 minutes
- 10 minutes
- 15 minutes
- 30 minutes
15 minutes
If two doses of benzodiazepines do not work for seizure management, what side effect do you consider and what should you consider to be the cause?
- Important side effect of BZD to consider
- Respiratory depression
- BZD internalization
- BZD ( receptors) GABAA (gamma‐aminobutyric acid) receptors move from the synaptic membrane to the cytoplasm, where they are functionally inactive.
What options are available for second line treatment in seizure management?
- Phenytoin
- 20 mg/kg iv load
- Can be diluted in 0.9% sodium chloride only
- Phenytoin must not be mixed with glucose solutions
- Max infusion rate of 1mg/kg/min, over 20 mins
- Stops seizures in 10-30 minutes
- Duration of action 24 hrs, T 1⁄2=24hr
- IV Levetiracetam (Keppra )
- 40 mg/kg rapidly infused ( 20-40 mg/kg)
- Can be loaded more rapidly over 5-10 minutes
- 2-4mg/kg/min (vs Phenytoin 1mg/kg /min)
- ( does not need serum levels )
- Phenobarbital (especially in infants)
- Lipid solubility < phenytoin
- Duration of action>48 hrs, T1/2= 100 hours
- Dose 20 mg/kg
- Side Effects: sedation, decreased respiration and BP
For second line option for seizure management, which is superior? (levetiracetam versus phenytoin)
- Levetiracetam was not superior
- Use either
- “Treatment with one drug followed by another reduced the failure rate by more than 50%”
- ( adding Levetiracetam added only 10 minutes to the treatment time )
- CONSIDER SEQUENTIAL USE – before the next standard of care – Intubation
Describe the algorithm for seizure management after second midazolam dose has been given
Describe the seizure management algorithm after the first choice of second line drug is given
What do you do if a patient is already on phenytoin or phenobarbitone?
If already on Phenytoin or Phenobarbitone halve the loading dose of same medication.
What is the chance of recurrence in an unprovoked first seizure?
20-25% may recur
What first aid do you do for focal seizures without awareness?
- DO
- Stay with the person
- Gently guide them away from harm
- Monitor airway and breathing
- Provide reassurance until recovered
- Time seizure
- DON’T
- Restrain the person unless in danger
When do you call 000 for an ambulance in an outpatient seizure?
- Person has breathing difficulty
- Injury has occurred
- There is food, vomit or fluid in mouth
- Seizure occurs in water
- Another seizure quickly follows
- Seizure lasts longer than 5 minutes
- The person is non-responsive for more than 5 minutes after the seizure stops
- You are unsure what to do
What are safety precautions to explain to parents for seizure management?
- Guide away from danger
- Position on the side
- Swimming – side lane with an adult closely watching (not on iphone!!)
- Biking – helmet – not on busy road
- Avoid Baths- Showers are preferred over baths
- Caution around locked door e.g. bathrooms
After resolution of a seizure, are there further investigations required?
- EEG
- ? MRI if focal
- LP if there is suspected meningitis
- Follow up – with paediatrician
What are the 4 key steps in managing a convulsive status epilepticus?
- Step 1 ABCDEFG & Cause
- Step 2 Medications – Midazolam
- Step 3 Phenytoin (+ Levetiracetam)
- Step 4 Intubation
- You are a GP trainee in your rooms. A 2 year old girl, Layla is brought in by the parents saying she had a brief “seizure” at home around 15-20 minutes back. The child is now asleep with normal vitals done by the nurse
- What would be the further relevant history
- Given - Brief event – few seconds, definitely under one minute -
- What happened before the episode?
- What was your child doing just before it started? Did anything appear to trigger the episode?
- How did the episode start?
- Any change in your child’s breathing or colour?
- Any loss of consciousness?
- Were they able to respond?
- Floppy or stiff?
- Did their arms and legs move? Jerks?
- Were their eyes open or closed?
- Did their head or eyes jerk or go to one side?
- How long did the episode last for, and how did you know it had finished?
- What was your child like after the episode, e.g., drowsy, sleepy, aggressive, etc?
- When was child was back to their usual self?
